As one of the most influential and successful actions in the global fight against AIDS, PEPFAR — short for the President’s Emergency Plan for AIDS Relief — long enjoyed the rarified air of bipartisan support in Washington. The program, credited for saving more than 26 million lives since its launch in 2003, was the crowning achievement of a Republican president, George W. Bush, and sailed through a series of reauthorization votes under both Republican and Democratic majorities in Congress.
Now, however, PEPFAR is facing an existential threat after finding itself in the crosshairs of partisan politics. Some legislators, alarmed by reports of 21 abortions performed through a PEPFAR-funded clinic in Mozambique, seem ready to end the program, whose one-year reauthorization expires on March 25.
If Congress fails to renew or modify the program in the next few weeks, prevention and treatment services that have been the cornerstone of global progress against HIV and AIDS will be severely disrupted. Some 20 million people living with HIV will lose access to medications they depend on to stay healthy. According to an analysis by the United Nations AIDS agency, UNAIDS, a long-term loss of PEPFAR funding would lead to a 10-fold increase in HIV-related deaths globally, costing around 6.3 million lives by the end of the decade.
But it doesn’t have to end like this for PEPFAR. Congress has an opportunity to do two important things at once: It can both save PEPFAR and improve it, acknowledging its essential role in the health of millions of people living with HIV, while also ensuring it becomes the nimbler, more efficient operation we need it to be to continue its success.
Several colleagues and I, drawing on decades of experience on the frontlines of HIV prevention and treatment, have outlined reforms that we believe can accomplish both of these goals. These proposals, which we describe in The Lancet HIV and in a policy brief by the Duke Global Health Institute, offer a roadmap for Congress to sustain PEPFAR’s remarkable legacy while realigning its strategy to better take on the changing landscape of HIV and AIDS globally.
Our recommendations flow from the recognition that the dynamics of the HIV pandemic have changed markedly since PEPFAR was formed in 2003, when a record-high 5 million new HIV cases were reported, according to UNAIDS. While breakthroughs in HIV treatment and prevention strategies have done much to reduce the number of new cases, they still remain alarmingly high in both wealthy and poor countries, and in fact are rising in places such as Peru, Brazil, The Philippines, Russia and parts of the United States. In 2023, for the first time, more than half of the 1.3 million new cases of HIV occurred outside sub-Saharan Africa, which has long been the focus of PEPFAR’s heaviest investments.
These statistics speak to PEPFAR’s success, but also to the critical need to broaden its scope. Expanding PEPFAR’s presence in Latin America, Eastern Europe, and Central and Southeast Asia can help regain traction in reducing new HIV cases, while also extending the soft-power influence of U.S. health diplomacy further into regions of strategic importance to the country’s foreign policy aims.
To accomplish this, however, PEPFAR needs a leaner, less bureaucratic approach that ensures that resources reach partner countries more directly and efficiently. We propose organizational and funding changes that will reduce program costs by 20 percent within five years. These include consolidating PEPFAR operations within the State Department, reducing redundancies in program implementation and evaluation and laying out a clearer path to transition program management to local leadership.
We also call on PEPFAR to focus prevention efforts on the most cost-effective interventions, such as the newly developed long-acting antiretroviral therapies, and to target groups at the highest risk of infection and transmission.
These reforms should resonate with political leadership on both sides of the aisle. But they cannot be implemented overnight, nor can you simply hit pause on a program that is so indispensable in the daily needs of millions of people living with HIV. The only path to both preserve PEPFAR and improve it is for Congress to agree on a new, five-year reauthorization, giving the program the space it needs to thoughtfully realign its operations and strategy.
Over the past few weeks, we have seen what a world without PEPFAR might look like. In the wake of the U.S. State Department’s Jan. 24 order to pause nearly all foreign aid, HIV clinics in many countries have been forced to close, causing chaos and confusion among both health care workers and people living with HIV.
For many of us, these scenes have brought harrowing echoes of the early days of the epidemic, when we had few effective ways to prevent death and suffering from AIDS and other HIV-related illnesses, and when we often had to tell people there was nothing we could do for them.
PEPFAR has been a critical piece of putting those days in the past, allowing us to harness scientific and clinical breakthroughs to give people living with HIV an opportunity to lead long, healthy lives. It would be a disgrace to turn our backs on them now, when the only thing we need to help them is the courage to act.
Chris Beyrer, M.D., is director of the Duke Global Health Institute and the Gary Hock Distinguished Professor of Medicine and Global Health at Duke University. He is a past president of the International AIDS Society and serves on a scientific advisory board for PEPFAR.
